Paeds IBD
Summary notes from Paeds update talk in 2023 Dr Li-Zsa Tan
Pathophysiology
Cause unknown
The theory is a complex interplay of genomics, epigenomics, gut microbiome and immune dysregulation
Disruption of mucous layer lining mucosa
More susceptible to pathogenic organisms that may trigger an immune response
Pathogens can enter lamina propria
Increases intestinal permeability
The immune system is exposed to the higher inflammatory burden
IL6, IL23, IL12
IBD gut has a perpetual cycle of inflammatory
IBD patients show a reduction in the number and diversity of gut microbiome species
No causal relationship to a specific bacteria, viral or fungus
Genetics
200 IBS risk-associated gene loci
Most are polygenic in nature
If monogenic cause, higher risk, more severe disease, manifests early, very symptomatic young
Course
Subclinical symptoms initially
Treatment initiated, symptoms terminated
Remission
Maintenance therapy
Flares and then further therapy to induce remission
If endoscopic remission is gained then much better outcomes
Histological remission
Categories
Crohn’s - patchy, whole gut, transmural
Ulcerative - mucosa, colon
IBD unclassified - colon, features of both UC and CD, usually in younger patients
Features
CD
Abdominal pain
Growth failure
Diarrhoea +/- bleeding
+/- Fistula (bowel to bowel, bowel to the skin, bowel to the vagina, bowel to the bladder)
UC
Blood diarrhoea
Urgency
Tenesmus
Abdominal pain
Goals
Improve QoL
Achieve timely physical growth and development
Optimise medical therapy
Go early go hard
40% of those who fail to achieve mucosal healing within 2 years go on to surgical management
Support consistent adherence
Minimise toxicity
Prevent disease complications
Support psycho-socio-emotional wellbeing
Support school attendance
Treatment
Infliximab and Adalibumab changed everything
TNF alpha inhibitors
IL12 / 23inhibitor
Anti alpha 4B7 integrin Ab
New small molecule therapeutics
JAK inhibitors
Diet and IBD
Deidre Burgess - Gastro Dietitian
EEN as first-line therapy in active paediatric crohn’s mild to moderate disease
6 to 8 weeks of nutritious liquid (Sustagen, Ensure plus + clear fluids)
73% remission rate in mild to moderate disease
Alternate CD Exclusion Diet
6 weeks of 50% energy from Ensure Plus
Chicken, Bananas, Apple, Potato
Nothing processed or packaged
Next 6 weeks are 25% energy from Ensure Plus
More foods
Effective at inducing remission with symptomatic score + blood tests, no endoscopic assessment
Still being investigated
Specific Carbohydrate Diet
No grains, very limited dairy
Study of SCD versus Mediterranean
No difference
Dietary Resources for patients and doctors
Monitoring
Minimise blood tests
Review colonoscopy when indicated
Faecal CP + stool cultures
MR enterography + U/S
Probiotics
2kg of bacteria
Most studies are in vitro
No great evidence yet, lots of studies ongoing
If active disease, step one is do no harm, go with proven evidence-based therapy with confirmed specific outcomes
Flares in GP
Paediatric patients have a specific phone line and email address for advice
